Central line-associated bloodstream infections (CLABSIs) are a big problem for patients because they often lead to serious complications such as sepsis. Further, managing such cases can significantly run up the tab for hospitals.
Consequently, when Lutheran Medical Center in Wheat Ridge, CO, noticed problems with performance regarding their CLABSI metrics just before the COVID-19 pandemic set in, they knew the issue needed to be addressed on a hospital-wide basis, since CLABSIs can occur on almost any unit, including the ED.
“We had seen quite an increase in our [CLABSI] rate,” explains Jessica Lowery, PhD, the infection prevention manager at Lutheran Medical Center. “We went from an average of zero or one CLABSI per year to as many as seven of these infections per year, so [in 2019] we really started digging in and seeing what we needed to do to get these infections under control.”
While the COVID-19 pandemic put the hospital’s active improvement efforts in this area on hold for a while, infection preventionists continued their work toward developing a solution during this period.
Lowery and her infection prevention colleagues met with nursing and physician leaders at the hospital to discuss the issue. They reviewed the latest guidance on CLABSI prevention from the Centers for Disease Control and Prevention (CDC), the Agency for Healthcare Research and Quality (AHRQ), and other professional organizations.
“We did a very thorough gap analysis of what we felt we were doing well and what we thought we could improve upon, and really targeted our interventions based on where we saw opportunities to improve,” states Lowery.
The infection preventionists identified several basic practices they thought needed to be reinforced, such as keeping eyes on the site where a central line is being placed, observes Lowery. “We also noticed we had a lot of opportunity around how we were collecting blood cultures, and even just how we were scrubbing the [central line] hub before administering medicines,” she says.
Another area of focus involved education around parts of the body where infections more commonly occur if they are selected for central line insertion. In particular, Lowery notes that CLABSIs are more common when central lines are placed in the femoral area because of the moisture level in this part of the body. Consequently, it is helpful to choose a different insertion site, if possible, she says.
The infection preventionists developed three tiers of interventions, beginning with some of the easier, basic improvements that they would focus on first. After a tier was mastered, they would then move on to the next tier of interventions, explains Lowery. Further, they selected an off-the-shelf education module on CLABSI that they could customize to target their specific characteristics and needs. “We worked with our nursing partners and our vascular access team, and we were able to develop our own questions and modify other questions toward where we thought we had the most opportunity to improve,” notes Lowery.
By having all the nurses complete the education module, administrators then were able to target prevention areas based on the responses of specific nurses or units to the various questions the module posed, explains Sara Reese, PhD, the director of infection prevention for Intermountain Health hospitals in Colorado and Montana. “When we could see, for example, that one unit at Lutheran Medical Center really struggled with a specific concept, we could target a specific intervention for that area rather than doing a hospital-wide intervention when it wasn’t needed because everybody else understood the concept,” says Reese, noting that this capability made the approach highly efficient.
“We rolled out the module to every nurse in the facility that we thought would have the opportunity to touch a central line,” states Lowery. “The only areas we excluded were labor and delivery and our postpartum units. Other than those areas, everybody was required to go through the module … and after the first round, we had a 98% completion rate,” she says.
This included all the nurses in the ED because a lot of central lines are placed in that area at Lutheran Medical Center, explains Lowery. Other points of emphasis for this project in the ED included making sure staff understood how to appropriately manage a central line, particularly in the case of patients who enter the ED with a central line. There was also a fair amount of review regarding proper line placement, how to properly change central line dressings, and the importance of maintaining a sterile field when placing a central line, particularly with respect to trauma patients, she says.
Lowery acknowledges that physicians needed to buy in to the improvement effort as well, given that they typically are the clinicians who actually insert the central lines. To get them on board, Lowery notes that the hospital’s infection prevention medical director, who also is a physician, took charge of meeting with the physicians, discussing the problem with CLABSIs and winning over their support.
After just one round of having all the nurses go through the module, along with some refresher training, it was clear the approach was working. “We made it through almost an entire year without a single CLABSI,” observes Lowery. “We did see an uptick in the summer of 2021, and at that point we decided that we wanted to make this an annual training activity for all nurses. Since we’ve done that, we’ve really maintained our decrease in the CLABSI infection rate. We have had just one CLABSI in the past two years.”
In Lowery’s view, the beauty of the training module is that it highlights for people processes or procedures they are doing that may not be in accordance with best practice. “I think it is easier than hearing this message from another person,” she says. “The computer telling someone that they gave a wrong answer probably goes over a little better.”
What also helps is having strong leadership support and a strong education team so that the improvement effort does not fall entirely on infection preventionists, adds Lowery. “Our chief nursing officer felt very, very strongly that we needed to get this accomplished — that we needed to get this education out and get the problem fixed, so she was able to convince everybody else in this facility that this was a focus area that needed to be prioritized.”
Reese adds that in addition to providing support, leaders also needed to take accountability. “If you have leadership that doesn’t value the importance of [infection prevention] all the way down to the patient level, then you are not going to get very far,” she says. “That was imperative to the success here.”
Further, Reese notes the approach used at Lutheran Medical Center has since been expanded to several other Intermountain Hospitals, many of which are experiencing similar success.
Editor’s note: The CDC offers an array of resources on preventing CLABSIs, including a checklist that healthcare organizations can use to guide their practices around placing central lines. You can access this information at https://www.cdc.gov/hai/bsi/bsi.html
Central line-associated bloodstream infections (CLABSIs) are a big problem for patients because they often lead to serious complications such as sepsis. Further, managing such cases can significantly run up the tab for hospitals.
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